Do You Ever Feel Like You're Going Crazy?

Do you ever feel like you're going crazy? Does your heart suddenly beat rapidly? Do you get the sweats waiting for a bus or the train? Do you feel impending doom when nothing is wrong? You may have panic attacks. Out of all the psychiatric illnesses, panic attacks are the easiest to treat and cure. There are medications and psychotherapies that can help you.

Nancy, a 56-year-old schoolteacher, was pleased to rid herself of panic attacks, from which she'd suffered for 10 years, by taking a daily dose of 10 milligrams of fluoxetine for two weeks. Additionally, she reluctantly agreed to a course of supportive, insight-oriented psychotherapy with me. Nancy wasn't convinced that she needed anything more than the medication, but because she was so happy to be panic-attack-free, she complied.

Three months into treatment she found that she became phobic of driving -- a fear she hadn't experienced before. Nancy thought that the new problem was very odd, because she had always loved to drive. Growing up in New Jersey, where a car is essential, she'd learned to drive at 17. To her driving was a symbol of freedom and independence, and she even kept a car in New York City, which proved to be expensive for her limited budget. Just before getting into her car, Nancy wouldn't have a panic attack, as she had in the past, but she would have a feeling of dread and a few bouts of diarrhea, and she'd sweat profusely. While driving she was worried about getting lost, even though she was familiar with the roads she'd driven over every day for years. She wanted to avoid driving, but she forced herself to do it anyway.

Sitting in her weekly psychotherapy session, she complained, "I never had this problem before. I can't continue being phobic of driving, since I have to visit relatives in New Jersey."

"Why do you think this problem is occurring now?" I asked.

"Uh, why now? The only thing I can think of is that the therapy brought it out." She didn't want to blame me, but she said she couldn't think of any other explanation, and I had insisted that she be perfectly honest with me.

"What about a driving phobia instead of the panic attacks?" I suggested.

"You mean I always need something wrong with me?"

"It seems that way to me," I said, leaning forward and looking very interested.

"You might be on the right track," she conceded. "As you know by now, I'm a very religious person. Father Nelson told us that the Devil always manifests in different ways. I conquered him in one form, and he popped up in another way."

"You mean the Devil could be a panic attack or a phobia. That's a good analogy," I said. "Your response to fluoxetine was really fast. You were free of panic attacks before we'd dealt with any of your real issues, like suppression of your emotions and the conflicted relationship with your mother."

Nancy sat quietly for a few moments thinking about what I said. "Do you think you'll be able to help me stop being afraid of driving and keep me panic-attack-free as well?"

"I think so, but then some other problem may arise until we delve deeply enough into those issues I mentioned."

"I don't want to be in therapy forever," she said. "My insurance won't pay for it. Besides I'm worried that the Devil will pop up in some other, more horrible way."

"We'll set a time limit of one year and then reevaluate after that," I promised.

"OK," Nancy agreed.

Nancy's quick recovery from panic attacks may have been a placebo response or a flight into health. Two weeks is usually too short a time for an antidepressant to work, either in panic disorder or depression. Patients will often have this kind of flight into health at the beginning of treatment and then lapse back into the disorder. However, Nancy agreed to explore her problems through psychotherapy, so that any return of symptoms could be addressed. Surprisingly enough, she didn't relapse into panic, but instead into a similar disorder, a specific phobia.

According to the DSM-IV-TR, the psychiatric book of diagnosis, a specific phobia is "a marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific situation" (in this case, driving). Driving didn't cause a panic attack but a terrible anxiety. Nancy feared that she would come to avoid driving altogether as she had avoided theaters and department stores when she had panic attacks. Driving was representative of freedom, and if she had to relinquish driving, it would be a great punishment for her. Psychoanalytical theory teaches that the major function of a phobia is a signal to the self that a forbidden, unconscious drive is pushing for conscious expression. Usually, specific phobias develop from the pairing of a specific situation with the emotions of fear and panic. Specific phobias tend to run in families, and Nancy's mother had both panic disorder and a phobia of driving.

Phobias often begin in childhood, but Nancy could not recall any from that time. It was as if a certain amount of unresolved conflict, negative energy or a Devil, as she called it, had to go somewhere, and panic attacks were no longer possible, so she developed a specific phobia.

Carol W. Berman, M.D. is a writer, psychiatrist and artist who lives and works in New York City. When she's not listening to patients, she's writing or painting. As an undergraduate she attended the University of California at Berkeley; she went to medical school at NYU Medical Center. Presently she is an Assistant Clinical Professor at NYU. She has practiced psychiatry for 25 years and is a member of the APA, ASJA and NWU. Her two books, "100 Questions and Answers About Panic Disorder" and "Personality Disorders," have helped thousands of patients deal with mental disorders. Read her blog on Red Room.